Appendix to the Global Burden of Viral Hepatitis

Transcription

1 Appendix to the Global Burden of Viral Hepatitis This appendix provides methodological details beyond those given in the core article, supplemental results, and citations for data sources used in the non-fatal and aetiological proportion models. Contents Appendix A: Methods... 2 A.1: Overall modelling framework for GBD A.2: Using DisMod to estimate acute infections... 2 A.3: Hepatitis B, chronic to acute conversion... 3 A.4: Acute hepatitis, proportion symptomatic... 3 A.5: Acute hepatitis E, case fatality... 4 A.6: Severity splits and disability weights... 5 A.7: CODEm models... 5 A.8: Aetiology splits... 7 A.9: Uncertainty... 8 A.10: Trend Decomposition... 8 A.11: Age-standardization... 9 Appendix B: Supplemental Results Appendix C: Data Sources C.1: Cirrhosis prevalence data by country C.2: Cirrhosis aetiology data C.3: Anti-HAV seroprevalence data by country C.4: HBsAg seroprevalence data by country C.5: Anti-HCV seroprevalence data C.6: Anti-HEV Seroprevalence C.7: Liver cancer aetiology data References

2 Appendix A: Methods A.1: Overall modelling framework for GBD 2013 Figure S1: GBD 2013 data and model flow chart A.2: Using DisMod to estimate acute infections DisMod-MR produces consistent estimates of disease incidence, prevalence, remission, and mortality using a non-linear mixed effects model to bring together all available data on the descriptive epidemiology of the disease of interest. DisMod-MR is an integrative systems model, which combines a system dynamics model of process with a statistical model of data. In DisMod- MR 2.0, the model of process is a two compartment stock-and-flow model, described by two ordinary differential equations, with the age-specific flows between a susceptible and a withcondition population. The model of data is an offset log-normal model, with hierarchical random effects on geography, age-standardized to address age-group heterogeneity. DisMod-MR model results include estimates of seroprevalence and instantaneous seroconversion rates (i.e. the incidence of seroconversion among the seronegative population). We converted these instantaneous seroconversion rates to population incidence rates (i.e. the number of infections per number in the total population) using the formula, population incidence rate = (instantaneous seroconversion rate) (1 - seroprevalence)

3 A.3: Hepatitis B, chronic to acute conversion HBsAg seropositivity typically persists only among chronic carriers and, by estimating incidence from a model of HBsAg seroprevalence, we are effectively modelling the incidence of HBV infections that result in chronic carriage. We, therefore, need to adjust these incidence estimates to estimate the incidence of all HBV infections (i.e. including those that result in chronic carriage and those that result in clearance). Knowing the proportion of infections that lead to the carrier state, we can simply divide our initial estimates by that proportion to estimate the total. It is clear, however, that this proportion varies enormously with age; so we must age-specific proportions to produce accurate estimates. Here, we use equations estimated by Edmunds et al 1 to calculate the probability that a new HBV infection will result in carriage, by age: PP(cccccccccccccc aaaaaa 6 mmmmmmmmhss) = PP(cccccccccccccc aaaaaa mmmmmmmmhss aaaaaa < 25 yyyyyyyyyy) = ee The oldest age group included in Edumunds s meta-analysis included people ages 20 to 30 years (treated as age = 25 years in their model). We are, therefore, not confident that their equation will hold for those older than 25 years of age, and take the conservative approach of assuming that the probability of developing the carrier state does not change with increasing age above 25 years: PP(cccccccccccccc aaaaaa 25 yyyyyyyyyy) = ee = A.4: Acute hepatitis, proportion symptomatic We used published age-specific formulae to estimate the probability of symptomatic infection for HAV 2 and HEV 3 : P(Symptomatic HAV) = (1 ee aaaaaa1.903 ) P(Symptomatic HEV) = PPPP mmmmmm (1 ee aaaaaa1.86 ) Where Prmax is the maximum probability of symptomatic acute infection among adults, and was assumed to be For HBV we developed a non-linear model of the age-specific probability of symptomatic acute infection based on data from McMahon et al 5 : P(Symptomatic HBV & age > 6 days) = ee (aaaaaa 29.6)

4 Figure S2: The probability that hepatitis B infection will result in chronic carriage, by age of infection McMahon et al did not report the probability of symptomatic acute infections among perinatal cases, but it is known to be a rare outcome, occurring in approximately only 1% of perinatal infections. 6 We, therefore assumed a probability of symptomatic acute infection of 0.01 in the first week of life: P(Symptomatic HBV & age 6 days) = 0.01 For HCV, we assumed that 25% of acute infections would be symptomatic based on a combination of expert opinion and published estimates. 7 A.5: Acute hepatitis E, case fatality We estimated the prevalence of pregnancy, Ppreg, among women for each country, year and age group based on age-specific fertility rates. We then estimated the acute hepatitis E case fatality among women as weighted average of the case fatalities among non-pregnant population, CFnonpreg, and among pregnant women, CFpreg: CCCC tttttttttt = CCCC pppppppp PP pppppppp + CCCC nnnnnn pppppppp (1 PP pppppppp )

5 Where CFpreg was assumed to be and CFnon-preg was assumed to be Case fatalities were assumed to be equal for males and non-pregnant females, or 0.38%. A.6: Severity splits and disability weights Symptomatic cases of acute HAV, HBV, HCV and HEV were split between mild, moderate and severe sequelae. Each sequela was assigned the disability of the most closely matching health state from the 235 GBD 2013 health states. For mild, moderate and severe acute hepatitis, these health states were Infectious disease, acute episode, mild (disability weight = [ ]), Infectious disease, acute episode, moderate (disability weight = [ ]) and Infectious disease, acute episode, severe (disability weight = [ ]), respectively. 8 Table S1: Proportion of symptomatic cases assigned to each of the three severity states, with the mean disability weight, by sub-type. Sub-type Mild Moderate Severe Mean Disability Weight Hepatitis A Hepatitis B Hepatitis C Hepatitis E For liver cancer the person-years for the four general sequelae were estimated. Cases that die within ten years experience only three sequelae: diagnosis/treatment, metastatic phase and terminal phase. Cases that survive beyond ten years experience disability due to diagnosis and treatment and remission. Duration of sequela 1 (Diagnosis and treatment) was four months, sequela 2 (controlled phase) was ten years for the survivors minus the duration of the other sequelae. Duration of sequela 3 (disseminated phase) was based on SEER data for median survival of patients with stage IV liver cancer (2.51 months). 9 A.7: CODEm models We used the Cause-of-Death Ensemble Model (CODEm) tool to model mortality from cirrhosis, liver cancer, and all acute-hepatitides combined. For each cause, the modeller specifies a list of potential covariates that may help inform the model. CODEm then tests combinations of covariates, using both linear and spacetime models, and with both mortality rate and causefraction as possible dependent variables. Each of these separate models is considered a submodel. Each sub-model is trained on 70% of the data and the remaining 30% are held out for out-of-sample prediction testing. The final predictions are based on combining results from multiple sub-models in which sub-models are weighted based on the out-of-sample prediction performance: the best performing sub-models have the strongest influence on the final predictions and poor performers have little or no influence. For each cause models are built separately for males and for females. Detailed information about CODEm was published previously. 10

6 We used two models for liver cancer: one model that included data from all countries was used to estimate liver cancer mortality for developing countries; and one model that included only data from developed countries and was used to estimate liver cancer mortality for developed countries. Cancer data from developed countries are substantially better than from developing countries. The poorer data from developing countries produces greater uncertainty in all estimates and, thus, erroneously inflates the uncertainty in estimates for developed countries. The two-model approach avoids this problem and allows uncertainty to be correctly estimated in developed countries. There are therefore four liver cancer mortality models: separate all country models for males and females, and separate developed country models for males and females. For cirrhosis, hepatitis and all-country liver cancer, both the male and female models included 55 sub-models each. The male and female developed country liver cancer models included 34 and 44 sub-models, respectively. The model types and dependent variables for these sub-models are given in Table S2. The potential covariates for each cause, and the number of included submodels that contained each covariate, are given in Table S3. Table S2: The number of sub-models in which the dependent variable was cause-fraction versus mortality rate, by model type, for each cause and sex. Cirrhosis Hepatitis Sex Females Males Females Males Model Type Dependent Variable Cause Fraction Rate Both Linear Spacetime Both Linear Spacetime Both Linear Spacetime Both Linear Spacetime Both Liver Cancer (all countries) Females Males Linear Spacetime Both Linear Spacetime Both Liver Cancer (developing countries) Linear Females Spacetime Both Males Linear Spacetime Both

7 Table S3: The number of models in which each covariate was used, among those models that were included in the final ensemble. For each cause-covariate combination, we give the number of models for which that covariate was included and, in parentheses, the percent of all models in the ensemble that contained that covariate. Hyphens ( - ) indicate that a given covariate was not specified as a potential covariate for that cause (i.e. sanitation was considered as a potential covariate in the cirrhosis model); whereas, zeros indicate that the covariate was included as a potential predictor for that cause, but that none of the models that included that covariate performed well enough to be included in the final ensemble. Cirrhosis Hepatitis Liver Cancer (all countries) Liver Cancer (developed) Covariate Alcohol (liters per capita) Animal fat (kcal per capita) BMI (mean) Females Males Females Males Females Males Females Males 25 (45.5) 26 (47.3) (30.9) 18 (32.7) - - Cigarettes per capita Cumulative cigarettes (15 year) Cumulative cigarettes (20 year) Diabetes prevalence Education (years per capita) Health system access (18.2) 21 (38.2) 0 (0.0) 18 (32.7) 19 (34.5) 0 (0.0) Hepatitis A seroprevalence - - Hepatitis B seroprevalence Hepatitis C seroprevalence 0 (0.0) 34 (61.8) 9 (16.4) 32 (58.2) Hepatitis E seroprevalence - - Log-lag distributed income (LDI), per capita Red meat (kcal per capital) Sanitation (proportion with access) Schistosomiasis prevalence Water (proportion with access to improved source) 16 (29.1) 22 (40.0) (60.0) 1 (1.8) 18 (32.7) 34 (61.8) 19 (34.5) 19 (34.5) 23 (41.8) 16 (29.1) 1 (1.8) 10 (18.2) 29 (52.7) 22 (40.0) 28 (50.9) 18 (32.7) (65.5) 26 (47.3) (41.8) 14 (25.5) 35 (63.6) 0 (0.0) 6 (10.9) 0 (0.0) 0 (0.0) 0 (0.0) 28 (50.9) 20 (36.4) 0 (0.0) 35 (63.6) 0 (0.0) 29 (52.7) 0 (0.0) 0 (0.0) 0 (0.0) 8 (14.5) 13 (23.6) 0 (0.0) 26 (59.1) 0 (0.0) 6 (13.6) 0 (0.0) 0 (0.0) 0 (0.0) 6 (13.6) 14 (31.8) 0 (0.0) 12 (35.3) 0 (0.0) 6 (17.6) 0 (0.0) 0 (0.0) 0 (0.0) 8 (23.5) 14 (41.2) 0 (0.0) (36.4) 28 (50.9) 21 (38.2) 33 (60.0) 16 (36.4) 28 (63.6) 14 (41.2) 16 (47.1) (23.6) 0 (0.0) 16 (29.1) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) (23.6) 17 (30.9) A.8: Aetiology splits We conducted literature reviews for studies that reported the prevalence of risk factors among those with cirrhosis or liver cancer. From each study we extracted the proportion of participants with evidence of chronic HBV infection, chronic HCV infection, history of excessive alcohol use, or other identifiable causes (e.g. non-alcoholic steatohepatitis (NASH), genetic causes). We excluded those with cryptogenic disease. In many studies some proportion of participants

8 present with multiple possible aetiologies (e.g. an individual with cirrhosis may be infected with both HBV and HCV). Unfortunately, data on comorbidities were too sparse to model each combination of aetiologies as separate aetiological entities. We therefore attempted to assign each case to a single cause. Where a study reports patients with multiple aetiologies, we split those patients between the possible aetiologies proportionally. As an example, we ll take a hypothetical study of 100 cirrhosis patients that reported 60 patients having a chronic hepatitis infection: 20 with HBV, 30 with HCV, and 10 with both HBV and HCV. We would split those 10 patients between HBV and HCV in a 20:30 ratio, giving us a 24 patients with cirrhosis due to HBV and 36 patients with cirrhosis due to HCV. For both cirrhosis and liver cancer, we run four separate DisMod models corresponding to each of the four potential aetiologies (i.e. alcohol, HBV, HCV, and other). Within each age, sex, year and location, we rescale the four proportion estimates to ensure that they sum to one, by dividing each proportion by the sum of the four. A.9: Uncertainty We propagate uncertainty through the modeling chain using posterior simulation. For all estimates we take 1,000 draws from the posterior distribution of the estimate. We then perform all subsequent calculations at the draw-level. For example, for the natural history model of acute hepatitis B deaths, for each age-sex-location-year, we take 1,000 random draws from the posterior distribution of our incidence estimate, and 1,000 random draws from the distribution of our estimate of case-fatality (based on a beta distribution). We then calculate 1,000 mortality rate draws, where draw one is equal to the product of the first incidence draw and the first casefatality draw. The mean of the 1,000 draws is then taken as the point estimate; the 2.5 th and 97.5 th percentile draws are taken as the lower and upper bounds of the 95% uncertainty interval. A.10: Trend Decomposition We decomposed overall trends in DALYs to determine the effects of population growth, changes in age-structure, and changes in age-specific rates using a counterfactual approach. We estimated a counterfactual estimate of the effect of population growth by taking the product of the all-age DALY rates for 1990 and the total 2013 population size: DDDDDDDDDD ggggggggggh = DDDDDDDDDD 1990 pppppp 1990 pppppp 2013 Where DALYsgrowth is the counterfactual estimate of the number of DALYs expected to have occurred in 2013 if only the population size changed (i.e. no changes in age-specific rates or agestructure); DALYS1990 is our estimate of the number of DALYs that occurred in 1990; and pop1990 and pop2013 are the total number of people in the population in 1990 and 2013, respectively.

9 Next, we estimated a counterfactual estimate of the number of DALYs that we expect to have occurred if only population size and age-structure changed, but age-specific rates remained static: 2 20 DDDDDDDDDD dddddddddd = DDDDDDDDDD 1990aaaa pppppp 2013aaaa ss=1 aa=1 pppppp 1990 aaaa Where DALYsdemog is the counterfactual estimate of the number of DALYs expected given only demographic changes; DDDDDDDDDD 1990 is our estimate of the number of DALYs that occurred in aaaa 1990 in age-group, a, and sex, s; and pppppp 1990 aaaa and pppppp are the number of people in the 2013aaaa population in age-group, a, sex, s, in 1990 and 2013, respectively. The change in DALYs attributable to population growth between 1990 and 2013 was calculated: DDDDDDDDDD ggggggggggh = DDDDDDDDDD ggggggggggh DDDDDDDDDD 1990 The change in DALYs attributable to overall demographic changes, including population growth and changes in age structure were calculated as, DDDDDDDDDD dddddddddd = DDDDDDDDDD dddddddddd DDDDDDDDDD 1990 The change in DALYs attributable to changes in age structure were calculated as, DDDDDDDDDD aaaaaa = DDDDDDDDDD dddddddddd DDDDDDDDDD ggggggggggh The total actual change in DALYs was calculated as, DDDDDDDDDD tttttttttt = DDDDDDDDDD 2013 DDDDDDDDDD 1990 Finally, the change in DALYs attributable to changes in age-specific rates was calculated as, DDDDDDDDDD rrrrrrrrrr = DDDDDDDDDD tttttttttt DDDDDDDDDD dddddddddd For each of the above components of change, we estimated percent change by dividing absolute change by the number of DALYs in A.11: Age-standardization Age-standardized rates were calculated by applying the age-specific rates for each location, sex and year to a standard population, using the equation, 2 20 rr llll = rr llllllll ww aaaa ss=1 aa=1 Where rly is the age-standardized rate in location, l, and year, y; rlyas is the age-specific rate in location, l, year, y, age, a, and sex, s; and was is the standard weight for age group, a, and sex, s.

10 Appendix B: Supplemental Results Table S4: Age-standardized rates of deaths, YLLs, YLDs and DALYs (per 100,000 person-years) attributable to viral hepatitis, by year with 95% uncertainty intervals in parentheses. Year Deaths (per 100k) YLLs (per 100k) YLDs (per 100k) DALYs (per 100k) (21.6, 23.6) (657.8, 723.9) 13.6 (9.4, 18.5) (671.2, 738.5) (22.7, 24.4) (678.1, 730.7) 13.3 (9.3, 18.1) (689.9, 743.6) (23.2, 24.9) (667.7, 718.9) 13.3 (9.4, 18.1) (680.0, 733.2) (22.8, 24.7) (639.9, 696.7) 13.1 (9.2, 17.7) (652.1, 709.5) (22.1, 24.4) (600.4, 674.1) 12.9 (9.1, 17.3) (612.0, 687.4) (21.5, 23.9) (574.1, 652.9) 12.5 (8.8, 16.8) (585.3, 667.1) Figure S3: Top 20 causes of DALYs for 1990 and 2013 (blue lines indicate decreased ranking, red lines indicate increased ranking)

11 Table S5: Rankings for deaths, YLLs, YLDs and DALYs attributable to viral hepatitis, by year, with 95% uncertainty intervals in parentheses. Year Deaths YLLs YLDs DALYs (10, 12) 18 (16, 20) 74 (72, 76) 22 (20, 25) (10, 12) 18 (15, 19) 74 (73, 77) 21 (19, 25) (10, 12) 15 (14, 16.5) 75 (73, 78) 20 (16, 22) (10, 12) 13 (13, 15) 76 (73, 79) 18 (15, 20) (8, 11) 13 (12, 14) 77 (73, 80) 18 (16, 20) (7, 8) 13 (11, 14) 76 (73, 80) 18 (16, 20) Table S6: The proportion of viral hepatitis deaths, YLLs, YLDs and DALYs attributable to each virus, by year, with 95% uncertainty intervals in parentheses. Year Etiology Deaths YLLs YLDs DALYs Hepatitis A (0.009, 0.044) (0.021, 0.100) (0.205, 0.275) (0.025, 0.103) Hepatitis B (0.554, 0.605) (0.532, 0.611) (0.485, 0.518) (0.531, 0.609) Hepatitis C (0.324, 0.352) (0.261, 0.286) (0.159, 0.220) (0.259, 0.285) Hepatitis E (0.043, 0.075) (0.074, 0.126) (0.060, 0.079) (0.074, 0.124) Hepatitis A (0.009, 0.041) (0.022, 0.094) (0.204, 0.279) (0.026, 0.097) Hepatitis B (0.535, 0.579) (0.518, 0.590) (0.466, 0.502) (0.517, 0.588) Hepatitis C (0.352, 0.376) (0.284, 0.307) (0.174, 0.237) (0.283, 0.306) Hepatitis E (0.040, 0.071) (0.072, 0.121) (0.059, 0.079) (0.072, 0.120) Hepatitis A (0.007, 0.033) (0.016, 0.074) (0.199, 0.275) (0.021, 0.078) Hepatitis B (0.521, 0.560) (0.515, 0.575) (0.456, 0.491) (0.514, 0.573) Hepatitis C (0.384, 0.407) (0.319, 0.345) (0.190, 0.257) (0.317, 0.343) Hepatitis E (0.034, 0.060) (0.061, 0.103) (0.057, 0.077) (0.061, 0.103) Hepatitis A (0.005, 0.025) (0.013, 0.059) (0.195, 0.271) (0.017, 0.062) Hepatitis B (0.491, 0.528) (0.491, 0.543) (0.444, 0.474) (0.491, 0.542) Hepatitis C (0.424, 0.454) (0.365, 0.399) (0.211, 0.283) (0.363, 0.396) Hepatitis E (0.028, 0.050) (0.051, 0.086) (0.053, 0.072) (0.051, 0.085) Hepatitis A (0.004, 0.021) (0.010, 0.049) (0.185, 0.265) (0.015, 0.053) Hepatitis B (0.456, 0.500) (0.469, 0.524) (0.435, 0.470) (0.469, 0.522) Hepatitis C (0.454, 0.494) (0.389, 0.432) (0.226, 0.297) (0.386, 0.429) Hepatitis E (0.027, 0.047) (0.050, 0.083) (0.052, 0.072) (0.050, 0.082) Hepatitis A (0.003, 0.019) (0.008, 0.044) (0.187, 0.265) (0.013, 0.048) Hepatitis B (0.449, 0.493) (0.460, 0.513) (0.423, 0.454) (0.459, 0.512) Hepatitis C (0.464, 0.504) (0.405, 0.450) (0.231, 0.312) (0.402, 0.447) Hepatitis E (0.025, 0.046) (0.046, 0.081) (0.054, 0.076) (0.046, 0.080)

12 Table S7: The proportion of viral hepatitis deaths, YLLs, YLDs and DALYs attributable to each cause, by year, with 95% uncertainty intervals Year Cause Deaths YLLs YLDs DALYs Acute hepatitis A (0.009, 0.044) (0.021, 0.100) (0.205, 0.275) (0.025, 0.103) Acute hepatitis B (0.074, 0.116) (0.093, 0.170) (0.224, 0.291) (0.097, 0.172) Acute hepatitis C (0.001, 0.006) (0.001, 0.007) (0.020, 0.025) (0.001, 0.008) Acute hepatitis E (0.043, 0.075) (0.074, 0.126) (0.060, 0.079) (0.074, 0.124) Cirrhosis of the liver due to hepatitis B (0.251, 0.273) (0.227, 0.250) (0.146, 0.219) (0.226, 0.249) Cirrhosis of the liver due to hepatitis C (0.224, 0.252) (0.188, 0.212) (0.112, 0.167) (0.187, 0.211) Liver cancer due to hepatitis B (0.209, 0.234) (0.188, 0.214) (0.048, 0.077) (0.185, 0.211) Liver cancer due to hepatitis C (0.090, 0.104) (0.065, 0.075) (0.022, 0.035) (0.064, 0.074) Acute hepatitis A (0.009, 0.041) (0.022, 0.094) (0.204, 0.279) (0.026, 0.097) Acute hepatitis B (0.063, 0.101) (0.079, 0.148) (0.195, 0.260) (0.082, 0.149) Acute hepatitis C (0.000, 0.005) (0.001, 0.006) (0.019, 0.025) (0.001, 0.007) Acute hepatitis E (0.040, 0.071) (0.072, 0.121) (0.059, 0.079) (0.072, 0.120) Cirrhosis of the liver due to hepatitis B (0.235, 0.261) (0.220, 0.244) (0.154, 0.225) (0.219, 0.243) Cirrhosis of the liver due to hepatitis C (0.221, 0.241) (0.189, 0.207) (0.117, 0.172) (0.188, 0.206) Liver cancer due to hepatitis B (0.217, 0.237) (0.199, 0.220) (0.053, 0.083) (0.196, 0.217) Liver cancer due to hepatitis C (0.122, 0.139) (0.088, 0.102) (0.031, 0.048) (0.087, 0.101) Acute hepatitis A (0.007, 0.033) (0.016, 0.074) (0.199, 0.275) (0.021, 0.078) Acute hepatitis B (0.055, 0.087) (0.064, 0.122) (0.184, 0.247) (0.067, 0.124) Acute hepatitis C (0.001, 0.006) (0.001, 0.007) (0.018, 0.023) (0.001, 0.007) Acute hepatitis E (0.034, 0.060) (0.061, 0.103) (0.057, 0.077) (0.061, 0.103) Cirrhosis of the liver due to hepatitis B (0.230, 0.250) (0.221, 0.244) (0.153, 0.222) (0.220, 0.243) Cirrhosis of the liver due to hepatitis C (0.217, 0.240) (0.195, 0.217) (0.124, 0.180) (0.194, 0.216) Liver cancer due to hepatitis B (0.220, 0.240) (0.210, 0.232) (0.057, 0.087) (0.206, 0.229) Liver cancer due to hepatitis C (0.154, 0.173) (0.114, 0.130) (0.041, 0.063) (0.112, 0.129) Acute hepatitis A (0.005, 0.025) (0.013, 0.059) (0.195, 0.271) (0.017, 0.062) Acute hepatitis B (0.042, 0.068) (0.049, 0.094) (0.173, 0.235) (0.052, 0.096) Acute hepatitis C (0.000, 0.005) (0.001, 0.007) (0.017, 0.023) (0.001, 0.007) Acute hepatitis E (0.028, 0.050) (0.051, 0.086) (0.053, 0.072) (0.051, 0.085) Cirrhosis of the liver due to hepatitis B (0.225, 0.249) (0.225, 0.250) (0.150, 0.215) (0.224, 0.249) Cirrhosis of the liver due to hepatitis C (0.232, 0.254) (0.215, 0.240) (0.134, 0.194) (0.213, 0.239) Liver cancer due to hepatitis B (0.206, 0.230) (0.197, 0.223) (0.057, 0.087) (0.194, 0.220) Liver cancer due to hepatitis C (0.183, 0.206) (0.141, 0.163) (0.051, 0.077) (0.140, 0.161) Acute hepatitis A (0.004, 0.021) (0.010, 0.049) (0.185, 0.265) (0.015, 0.053) Acute hepatitis B (0.037, 0.061) (0.044, 0.084) (0.157, 0.216) (0.046, 0.086) Acute hepatitis C (0.000, 0.005) (0.001, 0.006) (0.016, 0.022) (0.001, 0.007) Acute hepatitis E (0.027, 0.047) (0.050, 0.083) (0.052, 0.072) (0.050, 0.082) Cirrhosis of the liver due to hepatitis B (0.212, 0.239) (0.217, 0.249) (0.159, 0.226) (0.216, 0.248) Cirrhosis of the liver due to hepatitis C (0.230, 0.259) (0.213, 0.245) (0.135, 0.192) (0.212, 0.243) Liver cancer due to hepatitis B (0.190, 0.216) (0.188, 0.216) (0.060, 0.089) (0.185, 0.213) Liver cancer due to hepatitis C (0.212, 0.242) (0.166, 0.194) (0.064, 0.096) (0.164, 0.192) Acute hepatitis A (0.003, 0.019) (0.008, 0.044) (0.187, 0.265) (0.013, 0.048) Acute hepatitis B (0.036, 0.059) (0.041, 0.079) (0.167, 0.229) (0.044, 0.082) Acute hepatitis C (0.001, 0.006) (0.001, 0.007) (0.016, 0.022) (0.001, 0.007) Acute hepatitis E (0.025, 0.046) (0.046, 0.081) (0.054, 0.076) (0.046, 0.080) Cirrhosis of the liver due to hepatitis B (0.204, 0.232) (0.207, 0.239) (0.136, 0.195) (0.206, 0.237) Cirrhosis of the liver due to hepatitis C (0.231, 0.263) (0.221, 0.254) (0.137, 0.199) (0.220, 0.252) Liver cancer due to hepatitis B (0.193, 0.219) (0.191, 0.218) (0.061, 0.094) (0.189, 0.215) Liver cancer due to hepatitis C (0.221, 0.252) (0.175, 0.207) (0.069, 0.105) (0.173, 0.205)

13 Table S8: Age-standardized rates of deaths, YLLs, YLDs and DALYs (per 100,000 person-years) attributable to viral hepatitis by region, 2013 with 95% uncertainty intervals. Region Deaths (per 100k) YLLs (per 100k) YLDs (per 100k) DALYs (per 100k) Asia Pacific, High-income 22.5 (19.4, 27.8) (406.8, 610.5) 9.5 (6.7, 12.9) (415.7, 621.3) Asia, Central 36.7 (33.9, 40.6) 1,014.6 (932.1, 1,127.1) 19.3 (13.5, 26.0) 1,033.9 (952.4, 1,148.3) Asia, East 30.4 (27.0, 33.5) (668.5, 844.9) 16.4 (11.5, 21.9) (686.0, 861.9) Asia, South 24.4 (21.3, 28.5) (644.6, 882.9) 11.8 (8.3, 16.1) (656.8, 895.0) Asia, Southeast 28.2 (25.2, 31.7) (608.2, 794.0) 13.0 (9.2, 17.4) (622.5, 806.6) Australasia 7.2 (5.9, 8.3) (140.3, 190.4) 6.5 (4.4, 9.0) (146.2, 197.6) Caribbean 12.1 (10.9, 13.6) (250.2, 316.8) 7.3 (5.1, 10.0) (257.1, 323.2) Europe, Central 13.3 (12.1, 14.3) (314.3, 372.9) 10.3 (7.3, 14.0) (323.4, 384.3) Europe, Eastern 15.4 (13.9, 17.6) (439.4, 569.7) 11.2 (7.8, 15.3) (451.1, 580.1) Europe, Western 10.7 (9.7, 11.7) (220.9, 266.8) 7.3 (5.2, 9.9) (227.4, 274.7) Latin America, Andean 20.7 (18.0, 23.7) (385.5, 523.6) 7.5 (5.3, 10.3) (392.8, 531.4) Latin America, Central 18.9 (18.1, 19.8) (406.1, 446.2) 8.6 (6.0, 11.6) (413.8, 455.6) Latin America, Southern 13.1 (11.6, 14.7) (268.9, 351.9) 6.8 (4.7, 9.3) (275.3, 359.3) Latin America, Tropical 12.4 (10.1, 14.8) (256.5, 370.2) 6.8 (4.6, 9.2) (262.5, 377.9) North Africa / Middle East 31.4 (29.0, 34.0) (632.6, 756.1) 12.9 (9.1, 17.5) (644.5, 769.3) North America, High Income 10.1 (8.4, 12.0) (219.1, 313.8) 6.4 (4.4, 8.7) (225.2, 320.4) Oceania 42.2 (27.7, 60.8) 1,352.9 (866.8, 2,018.9) 15.6 (10.8, 21.4) 1,368.5 (878.8, 2,034.2) Sub-Saharan Africa, Central 25.3 (21.5, 29.5) (565.3, 783.0) 15.4 (10.6, 20.9) (580.0, 797.8) Sub-Saharan Africa, East 20.4 (18.8, 22.1) (477.0, 570.6) 14.3 (10.0, 19.4) (490.5, 584.5) Sub-Saharan Africa, Southern 9.8 (8.6, 11.3) (217.8, 287.4) 10.1 (6.9, 14.0) (227.7, 297.7) Sub-Saharan Africa, West 35.0 (30.9, 39.3) (801.3, 1,028.0) 18.8 (13.2, 25.4) (819.6, 1,047.1) Table S9: Combined viral hepatitis ranking in terms of deaths, YLLs, YLDs and DALYs by region, 2013 with 95% uncertainty intervals Region Deaths YLLs YLDs DALYs Asia Pacific, High Income 6 (5, 8) 5 (2, 7) 65 (57, 67) 7 (4, 13) Asia, Central 4 (4, 4) 5 (5, 7) 55 (51.5, 56) 8 (6, 10) Asia, East 5 (5, 5) 4 (4, 6) 55 (51, 57) 6 (6, 9) Asia, South 12 (9, 14) 13 (11, 15) 72 (70, 74) 18 (14, 21) Asia, Southeast 7 (6, 8) 8 (6, 10) 70 (67, 72) 12 (10, 17) Australasia 16 (14, 21) 11 (11, 16) 74 (70, 80) 27 (25, 35) Caribbean 16 (14, 19) 20 (18, 25) 76 (74, 78) 34 (29, 39) Europe, Central 10 (10, 13) 8 (7, 11) 65 (61, 67) 17 (14.5, 20) Europe, Eastern 10 (9, 12) 7 (7, 11) 65 (61, 67) 13 (11, 19) Europe, Western 13 (11, 15) 10 (8, 10) 68 (66, 72) 21 (17, 25) Latin America, Andean 9 (8, 10) 12 (10, 16) 77 (74, 80) 22 (20, 27) Latin America, Central 11 (10, 11) 12 (12, 13) 77 (72, 78) 20 (17, 23) Latin America, Southern 15 (11, 16) 14 (10, 16) 76 (75, 79) 25 (20, 28) Latin America, Tropical 13 (11, 17) 13 (10, 16) 72 (69, 76) 24 (19, 29) North Africa / Middle East 5 (4, 6) 7 (7, 8) 63 (60, 66) 16 (12, 18) North America, High Income 12 (10, 17) 11 (8, 14) 78 (75, 81) 21 (19, 28) Oceania 8 (7, 10) 5 (5, 13) 62 (61, 66) 8 (5, 17) Sub-Saharan Africa, Central 23 (18, 25) 25 (22, 31) 73 (70, 75) 32 (28, 39) Sub-Saharan Africa, East 20 (19, 23) 24 (22, 26) 74 (72, 76) 32 (29, 36) Sub-Saharan Africa, Southern 29 (25, 31.5) 30 (28, 34) 76 (75, 78) 41 (38, 48) Sub-Saharan Africa, West 16 (15, 17) 18 (17, 21) 70 (65, 71) 23 (20, 26)

14 Table S10: The proportion of viral hepatitis deaths, YLLs, YLDs and DALYs attributable to each virus, by region, 2013 with 95% uncertainty intervals Region Etiology Deaths YLLs YLDs DALYs Asia Pacific, High-income Asia, Central Asia, East Asia, South Asia, Southeast Australasia Caribbean Europe, Central Europe, Eastern Europe, Western Latin America, Andean Hepatitis A (0.000, 0.001) (0.000, 0.001) (0.110, 0.199) (0.002, 0.005) Hepatitis B (0.231, 0.314) (0.285, 0.377) (0.270, 0.347) (0.285, 0.377) Hepatitis C (0.686, 0.769) (0.622, 0.714) (0.476, 0.601) (0.620, 0.711) Hepatitis E (0.000, 0.000) (0.000, 0.000) (0.000, 0.000) (0.000, 0.000) Hepatitis A (0.002, 0.011) (0.004, 0.026) (0.128, 0.195) (0.008, 0.029) Hepatitis B (0.565, 0.650) (0.570, 0.662) (0.541, 0.610) (0.570, 0.660) Hepatitis C (0.337, 0.422) (0.310, 0.401) (0.208, 0.285) (0.308, 0.399) Hepatitis E (0.005, 0.012) (0.010, 0.022) (0.015, 0.023) (0.010, 0.022) Hepatitis A (0.001, 0.006) (0.001, 0.010) (0.121, 0.173) (0.004, 0.013) Hepatitis B (0.548, 0.624) (0.559, 0.643) (0.553, 0.590) (0.559, 0.642) Hepatitis C (0.358, 0.435) (0.330, 0.416) (0.178, 0.252) (0.327, 0.413) Hepatitis E (0.009, 0.023) (0.013, 0.032) (0.058, 0.082) (0.015, 0.033) Hepatitis A (0.012, 0.063) (0.026, 0.125) (0.229, 0.324) (0.030, 0.128) Hepatitis B (0.450, 0.575) (0.402, 0.542) (0.326, 0.437) (0.401, 0.540) Hepatitis C (0.276, 0.379) (0.222, 0.318) (0.159, 0.260) (0.222, 0.316) Hepatitis E (0.096, 0.164) (0.147, 0.239) (0.112, 0.165) (0.147, 0.237) Hepatitis A (0.001, 0.005) (0.002, 0.010) (0.199, 0.285) (0.006, 0.015) Hepatitis B (0.494, 0.575) (0.511, 0.605) (0.456, 0.514) (0.510, 0.603) Hepatitis C (0.410, 0.493) (0.375, 0.466) (0.188, 0.276) (0.372, 0.463) Hepatitis E (0.006, 0.015) (0.011, 0.023) (0.032, 0.048) (0.011, 0.023) Hepatitis A (0.001, 0.011) (0.002, 0.018) (0.233, 0.343) (0.011, 0.028) Hepatitis B (0.265, 0.438) (0.309, 0.476) (0.332, 0.426) (0.311, 0.474) Hepatitis C (0.556, 0.731) (0.517, 0.682) (0.263, 0.406) (0.510, 0.672) Hepatitis E (0.000, 0.000) (0.000, 0.000) (0.000, 0.000) (0.000, 0.000) Hepatitis A (0.005, 0.019) (0.012, 0.041) (0.333, 0.445) (0.022, 0.050) Hepatitis B (0.222, 0.306) (0.244, 0.340) (0.266, 0.325) (0.245, 0.340) Hepatitis C (0.684, 0.766) (0.637, 0.727) (0.251, 0.380) (0.627, 0.717) Hepatitis E (0.000, 0.000) (0.000, 0.000) (0.000, 0.000) (0.000, 0.000) Hepatitis A (0.000, 0.002) (0.001, 0.003) (0.142, 0.237) (0.005, 0.009) Hepatitis B (0.397, 0.486) (0.419, 0.515) (0.381, 0.472) (0.418, 0.514) Hepatitis C (0.513, 0.602) (0.483, 0.580) (0.336, 0.441) (0.479, 0.576) Hepatitis E (0.000, 0.000) (0.000, 0.000) (0.000, 0.000) (0.000, 0.000) Hepatitis A (0.001, 0.003) (0.001, 0.005) (0.132, 0.225) (0.004, 0.009) Hepatitis B (0.235, 0.377) (0.243, 0.395) (0.269, 0.398) (0.244, 0.395) Hepatitis C (0.622, 0.763) (0.603, 0.754) (0.418, 0.575) (0.599, 0.750) Hepatitis E (0.000, 0.000) (0.000, 0.000) (0.000, 0.000) (0.000, 0.000) Hepatitis A (0.001, 0.006) (0.002, 0.008) (0.169, 0.276) (0.007, 0.014) Hepatitis B (0.194, 0.245) (0.204, 0.261) (0.185, 0.226) (0.203, 0.260) Hepatitis C (0.752, 0.803) (0.734, 0.791) (0.518, 0.632) (0.729, 0.787) Hepatitis E (0.000, 0.000) (0.000, 0.000) (0.000, 0.000) (0.000, 0.000) Hepatitis A (0.003, 0.009) (0.007, 0.022) (0.372, 0.509) (0.015, 0.031) Hepatitis B (0.336, 0.477) (0.350, 0.486) (0.258, 0.339) (0.348, 0.483) Hepatitis C (0.518, 0.657) (0.499, 0.636) (0.207, 0.325) (0.494, 0.630) Hepatitis E (0.000, 0.000) (0.000, 0.000) (0.000, 0.000) (0.000, 0.000)

15 Table S10 (continued): The proportion of viral hepatitis deaths, YLLs, YLDs and DALYs attributable to each virus, by region, 2013 with 95% uncertainty intervals Region Etiology Deaths YLLs YLDs DALYs Latin America, Central Latin America, Southern Latin America, Tropical Hepatitis A (0.002, 0.009) (0.006, 0.017) (0.312, 0.418) (0.013, 0.026) Hepatitis B (0.153, 0.176) (0.160, 0.185) (0.246, 0.287) (0.162, 0.187) Hepatitis C (0.819, 0.841) (0.804, 0.828) (0.303, 0.437) (0.793, 0.818) Hepatitis E (0.000, 0.000) (0.000, 0.000) (0.000, 0.000) (0.000, 0.000) Hepatitis A (0.004, 0.013) (0.008, 0.020) (0.288, 0.450) (0.015, 0.029) Hepatitis B (0.140, 0.275) (0.139, 0.272) (0.102, 0.190) (0.139, 0.270) Hepatitis C (0.718, 0.851) (0.714, 0.845) (0.408, 0.571) (0.708, 0.839) Hepatitis E (0.000, 0.000) (0.000, 0.000) (0.000, 0.000) (0.000, 0.000) Hepatitis A (0.003, 0.016) (0.006, 0.025) (0.339, 0.484) (0.014, 0.035) Hepatitis B (0.164, 0.296) (0.171, 0.321) (0.182, 0.267) (0.172, 0.320) Hepatitis C (0.695, 0.827) (0.665, 0.814) (0.286, 0.457) (0.657, 0.805) Hepatitis E (0.000, 0.000) (0.000, 0.000) (0.000, 0.000) (0.000, 0.000) Hepatitis A (0.001, 0.007) (0.003, 0.015) (0.220, 0.302) (0.008, 0.021) Hepatitis B North Africa and Middle East (0.324, 0.478) (0.329, 0.478) (0.365, 0.419) (0.330, 0.478) Hepatitis C (0.509, 0.662) (0.498, 0.650) (0.234, 0.330) (0.493, 0.642) North America, High Income Oceania Sub-Saharan Africa, Central Sub-Saharan Africa, East Hepatitis E (0.006, 0.015) (0.009, 0.021) (0.054, 0.075) (0.010, 0.022) Hepatitis A (0.003, 0.013) (0.004, 0.016) (0.204, 0.348) (0.009, 0.022) Hepatitis B (0.118, 0.217) (0.123, 0.222) (0.114, 0.192) (0.122, 0.221) Hepatitis C (0.776, 0.874) (0.766, 0.868) (0.491, 0.659) (0.761, 0.863) Hepatitis E (0.000, 0.000) (0.000, 0.000) (0.000, 0.000) (0.000, 0.000) Hepatitis A (0.004, 0.028) (0.006, 0.052) (0.192, 0.276) (0.009, 0.055) Hepatitis B (0.630, 0.758) (0.628, 0.761) (0.489, 0.580) (0.626, 0.759) Hepatitis C (0.172, 0.288) (0.148, 0.264) (0.111, 0.195) (0.147, 0.263) Hepatitis E (0.036, 0.098) (0.046, 0.115) (0.067, 0.098) (0.046, 0.115) Hepatitis A (0.005, 0.035) (0.011, 0.078) (0.238, 0.319) (0.019, 0.084) Hepatitis B (0.361, 0.534) (0.373, 0.532) (0.345, 0.442) (0.373, 0.529) Hepatitis C (0.370, 0.603) (0.315, 0.555) (0.193, 0.307) (0.312, 0.544) Hepatitis E (0.015, 0.077) (0.025, 0.109) (0.066, 0.091) (0.026, 0.108) Hepatitis A (0.004, 0.024) (0.010, 0.054) (0.267, 0.341) (0.021, 0.063) Hepatitis B (0.440, 0.547) (0.455, 0.558) (0.449, 0.501) (0.456, 0.556) Hepatitis C (0.411, 0.514) (0.367, 0.460) (0.128, 0.205) (0.359, 0.450) Hepatitis E (0.019, 0.041) (0.032, 0.065) (0.046, 0.062) (0.033, 0.065) Hepatitis A (0.008, 0.050) (0.017, 0.098) (0.280, 0.368) (0.031, 0.108) Hepatitis B Sub-Saharan Africa, Southern (0.434, 0.590) (0.438, 0.606) (0.410, 0.504) (0.438, 0.599) Hepatitis C (0.314, 0.472) (0.236, 0.388) (0.120, 0.220) (0.233, 0.381) Sub-Saharan Africa, West Hepatitis E (0.038, 0.102) (0.066, 0.168) (0.038, 0.055) (0.065, 0.164) Hepatitis A (0.002, 0.021) (0.006, 0.047) (0.201, 0.262) (0.012, 0.051) Hepatitis B (0.539, 0.633) (0.561, 0.656) (0.482, 0.550) (0.560, 0.653) Hepatitis C (0.324, 0.431) (0.276, 0.386) (0.152, 0.224) (0.274, 0.381) Hepatitis E (0.014, 0.047) (0.021, 0.065) (0.054, 0.077) (0.023, 0.065)

16 Table S11: The proportion of viral hepatitis deaths, YLLs, YLDs and DALYs attributable to each cause, by region, 2013 with 95% uncertainty intervals Region Cause Deaths YLLs YLDs DALYs Acute hepatitis A (0.000, 0.001) (0.000, 0.001) (0.110, 0.199) (0.002, 0.005) Acute hepatitis B (0.003, 0.005) (0.003, 0.005) (0.065, 0.124) (0.004, 0.007) Acute hepatitis C (0.000, 0.000) (0.000, 0.000) (0.011, 0.023) (0.000, 0.001) Asia Pacific, Acute hepatitis E (0.000, 0.000) (0.000, 0.000) (0.000, 0.000) (0.000, 0.000) High Income Cirrhosis hepatitis B (0.094, 0.153) (0.106, 0.176) (0.080, 0.133) (0.105, 0.175) Cirrhosis hepatitis C (0.122, 0.247) (0.118, 0.236) (0.107, 0.205) (0.118, 0.235) Liver cancer hepatitis B (0.110, 0.177) (0.143, 0.228) (0.084, 0.147) (0.142, 0.227) Liver cancer hepatitis C (0.486, 0.607) (0.428, 0.566) (0.294, 0.451) (0.426, 0.563) Acute hepatitis A (0.002, 0.011) (0.004, 0.026) (0.128, 0.195) (0.008, 0.029) Acute hepatitis B (0.016, 0.028) (0.029, 0.056) (0.162, 0.249) (0.032, 0.059) Acute hepatitis C (0.000, 0.004) (0.001, 0.007) (0.026, 0.039) (0.001, 0.008) Asia, Central Acute hepatitis E (0.005, 0.012) (0.010, 0.022) (0.015, 0.023) (0.010, 0.022) Cirrhosis hepatitis B (0.444, 0.527) (0.443, 0.533) (0.283, 0.402) (0.441, 0.530) Cirrhosis hepatitis C (0.239, 0.325) (0.232, 0.325) (0.148, 0.227) (0.231, 0.323) Liver cancer hepatitis B (0.092, 0.112) (0.079, 0.098) (0.023, 0.036) (0.078, 0.097) Liver cancer hepatitis C (0.086, 0.105) (0.067, 0.083) (0.021, 0.033) (0.066, 0.082) Acute hepatitis A (0.001, 0.006) (0.001, 0.010) (0.121, 0.173) (0.004, 0.013) Acute hepatitis B (0.042, 0.063) (0.039, 0.065) (0.223, 0.313) (0.043, 0.069) Acute hepatitis C (0.000, 0.004) (0.000, 0.004) (0.012, 0.016) (0.001, 0.004) Asia, East Acute hepatitis E (0.009, 0.023) (0.013, 0.032) (0.058, 0.082) (0.015, 0.033) Cirrhosis hepatitis B (0.154, 0.175) (0.152, 0.175) (0.123, 0.180) (0.152, 0.175) Cirrhosis hepatitis C (0.077, 0.089) (0.077, 0.089) (0.061, 0.092) (0.077, 0.088) Liver cancer hepatitis B (0.336, 0.403) (0.350, 0.420) (0.120, 0.190) (0.345, 0.416) Liver cancer hepatitis C (0.273, 0.352) (0.247, 0.332) (0.094, 0.157) (0.244, 0.328) Acute hepatitis A (0.012, 0.063) (0.026, 0.125) (0.229, 0.324) (0.030, 0.128) Acute hepatitis B (0.060, 0.123) (0.063, 0.157) (0.094, 0.143) (0.064, 0.157) Acute hepatitis C (0.001, 0.012) (0.001, 0.014) (0.014, 0.021) (0.001, 0.014) Asia, South Acute hepatitis E (0.096, 0.164) (0.147, 0.239) (0.112, 0.165) (0.147, 0.237) Cirrhosis hepatitis B (0.247, 0.344) (0.213, 0.313) (0.165, 0.286) (0.212, 0.312) Cirrhosis hepatitis C (0.163, 0.261) (0.138, 0.230) (0.108, 0.203) (0.138, 0.229) Liver cancer hepatitis B (0.100, 0.154) (0.078, 0.128) (0.030, 0.058) (0.077, 0.127) Liver cancer hepatitis C (0.089, 0.132) (0.064, 0.096) (0.027, 0.050) (0.063, 0.095) Acute hepatitis A (0.001, 0.005) (0.002, 0.010) (0.199, 0.285) (0.006, 0.015) Acute hepatitis B (0.016, 0.026) (0.017, 0.031) (0.185, 0.266) (0.020, 0.035) Acute hepatitis C (0.000, 0.001) (0.000, 0.002) (0.013, 0.018) (0.000, 0.002) Asia, Southeast Acute hepatitis E (0.006, 0.015) (0.011, 0.023) (0.032, 0.048) (0.011, 0.023) Cirrhosis hepatitis B (0.241, 0.323) (0.257, 0.355) (0.137, 0.215) (0.255, 0.351) Cirrhosis hepatitis C (0.173, 0.259) (0.177, 0.271) (0.096, 0.165) (0.176, 0.269) Liver cancer hepatitis B (0.191, 0.273) (0.184, 0.269) (0.067, 0.115) (0.182, 0.266) Liver cancer hepatitis C (0.194, 0.288) (0.160, 0.248) (0.065, 0.115) (0.158, 0.245) Acute hepatitis A (0.001, 0.011) (0.002, 0.018) (0.233, 0.343) (0.011, 0.028) Acute hepatitis B (0.042, 0.070) (0.058, 0.096) (0.190, 0.282) (0.063, 0.102) Acute hepatitis C (0.001, 0.009) (0.001, 0.013) (0.024, 0.043) (0.002, 0.013) Australasia Acute hepatitis E (0.000, 0.000) (0.000, 0.000) (0.000, 0.000) (0.000, 0.000) Cirrhosis hepatitis B (0.109, 0.249) (0.120, 0.252) (0.062, 0.146) (0.119, 0.247) Cirrhosis hepatitis C (0.236, 0.405) (0.256, 0.421) (0.136, 0.251) (0.253, 0.415) Liver cancer hepatitis B (0.085, 0.171) (0.092, 0.186) (0.027, 0.068) (0.090, 0.182) Liver cancer hepatitis C (0.246, 0.409) (0.191, 0.334) (0.070, 0.154) (0.187, 0.328)

17 Table S11 (continued): The proportion of viral hepatitis deaths, YLLs, YLDs and DALYs attributable to each cause, by region, 2013 with 95% uncertainty intervals Region Cause Deaths YLLs YLDs DALYs Caribbean Europe, Central Europe, Eastern Europe, Western Latin America, Andean Latin America, Central Acute hepatitis A (0.005, 0.019) (0.012, 0.041) (0.333, 0.445) (0.022, 0.050) Acute hepatitis B (0.027, 0.044) (0.032, 0.060) (0.171, 0.235) (0.036, 0.064) Acute hepatitis C (0.001, 0.009) (0.001, 0.014) (0.020, 0.028) (0.002, 0.014) Acute hepatitis E (0.000, 0.000) (0.000, 0.000) (0.000, 0.000) (0.000, 0.000) Cirrhosis hepatitis B (0.079, 0.150) (0.084, 0.162) (0.037, 0.082) (0.082, 0.159) Cirrhosis hepatitis C (0.412, 0.515) (0.406, 0.511) (0.160, 0.265) (0.399, 0.504) Liver cancer hepatitis B (0.093, 0.136) (0.101, 0.149) (0.027, 0.052) (0.100, 0.146) Liver cancer hepatitis C (0.220, 0.286) (0.181, 0.242) (0.058, 0.105) (0.179, 0.238) Acute hepatitis A (0.000, 0.002) (0.001, 0.003) (0.142, 0.237) (0.005, 0.009) Acute hepatitis B (0.003, 0.005) (0.003, 0.005) (0.053, 0.090) (0.004, 0.007) Acute hepatitis C (0.000, 0.001) (0.000, 0.001) (0.011, 0.018) (0.000, 0.001) Acute hepatitis E (0.000, 0.000) (0.000, 0.000) (0.000, 0.000) (0.000, 0.000) Cirrhosis hepatitis B (0.295, 0.389) (0.327, 0.423) (0.279, 0.382) (0.326, 0.421) Cirrhosis hepatitis C (0.307, 0.391) (0.323, 0.417) (0.264, 0.365) (0.322, 0.415) Liver cancer hepatitis B (0.073, 0.114) (0.067, 0.105) (0.020, 0.036) (0.066, 0.103) Liver cancer hepatitis C (0.175, 0.236) (0.134, 0.187) (0.045, 0.073) (0.131, 0.183) Acute hepatitis A (0.001, 0.003) (0.001, 0.005) (0.132, 0.225) (0.004, 0.009) Acute hepatitis B (0.004, 0.007) (0.005, 0.009) (0.077, 0.137) (0.007, 0.012) Acute hepatitis C (0.000, 0.001) (0.000, 0.001) (0.013, 0.025) (0.000, 0.001) Acute hepatitis E (0.000, 0.000) (0.000, 0.000) (0.000, 0.000) (0.000, 0.000) Cirrhosis hepatitis B (0.181, 0.324) (0.199, 0.350) (0.152, 0.282) (0.198, 0.348) Cirrhosis hepatitis C (0.477, 0.623) (0.499, 0.656) (0.359, 0.515) (0.497, 0.653) Liver cancer hepatitis B (0.033, 0.063) (0.027, 0.052) (0.009, 0.020) (0.027, 0.051) Liver cancer hepatitis C (0.112, 0.180) (0.078, 0.131) (0.030, 0.055) (0.077, 0.129) Acute hepatitis A (0.001, 0.006) (0.002, 0.008) (0.169, 0.276) (0.007, 0.014) Acute hepatitis B (0.008, 0.014) (0.007, 0.014) (0.043, 0.074) (0.009, 0.015) Acute hepatitis C (0.000, 0.003) (0.000, 0.003) (0.012, 0.019) (0.001, 0.003) Acute hepatitis E (0.000, 0.000) (0.000, 0.000) (0.000, 0.000) (0.000, 0.000) Cirrhosis hepatitis B (0.093, 0.129) (0.099, 0.137) (0.079, 0.119) (0.098, 0.136) Cirrhosis hepatitis C (0.411, 0.499) (0.449, 0.546) (0.357, 0.467) (0.448, 0.543) Liver cancer hepatitis B (0.081, 0.119) (0.084, 0.127) (0.038, 0.062) (0.083, 0.125) Liver cancer hepatitis C (0.287, 0.362) (0.235, 0.307) (0.118, 0.181) (0.232, 0.304) Acute hepatitis A (0.003, 0.009) (0.007, 0.022) (0.372, 0.509) (0.015, 0.031) Acute hepatitis B (0.010, 0.017) (0.011, 0.024) (0.105, 0.148) (0.013, 0.026) Acute hepatitis C (0.000, 0.003) (0.000, 0.005) (0.018, 0.025) (0.001, 0.005) Acute hepatitis E (0.000, 0.000) (0.000, 0.000) (0.000, 0.000) (0.000, 0.000) Cirrhosis hepatitis B (0.170, 0.297) (0.172, 0.297) (0.068, 0.141) (0.170, 0.293) Cirrhosis hepatitis C (0.458, 0.590) (0.454, 0.587) (0.161, 0.274) (0.449, 0.582) Liver cancer hepatitis B (0.137, 0.191) (0.142, 0.201) (0.052, 0.094) (0.141, 0.198) Liver cancer hepatitis C (0.047, 0.083) (0.034, 0.058) (0.019, 0.039) (0.034, 0.058) Acute hepatitis A (0.002, 0.009) (0.006, 0.017) (0.312, 0.418) (0.013, 0.026) Acute hepatitis B (0.009, 0.016) (0.010, 0.020) (0.171, 0.234) (0.013, 0.024) Acute hepatitis C (0.001, 0.006) (0.001, 0.008) (0.026, 0.034) (0.002, 0.008) Acute hepatitis E (0.000, 0.000) (0.000, 0.000) (0.000, 0.000) (0.000, 0.000) Cirrhosis hepatitis B (0.054, 0.066) (0.061, 0.074) (0.022, 0.036) (0.060, 0.074) Cirrhosis hepatitis C (0.638, 0.670) (0.658, 0.690) (0.221, 0.335) (0.649, 0.682) Liver cancer hepatitis B (0.082, 0.103) (0.081, 0.100) (0.026, 0.045) (0.080, 0.099) Liver cancer hepatitis C (0.161, 0.186) (0.128, 0.150) (0.047, 0.080) (0.126, 0.148)